PPE in Hospital
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Philippine COVID-19 Living Clinical Practice Guidelines Institute of Clinical Epidemiology, National Institutes of Health, UP Manila In cooperation with the Philippine Society for Microbiology and Infectious Diseases Funded by the DOH AHEAD Program through the PCHRD EVIDENCE SUMMARY Among health care workers how effective is the use of personal protective equipment in the wards, ICU, and emergency room in the prevention of COVID 19 infection? Evidence Reviewers: Germana Emerita V. Gregorio, MD, Rowena F. Genuino, MD, MSc, Howell Henrian G Bayona, MSc, CSP-PASP PPE in Hospital RECOMMENDATION We recommend the use of the following PPE: disposable hat, medical protective mask (N95 or higher standard), goggles or face shield (anti-fog), medical protective clothing, disposable gloves and disposable shoe covers or dedicated closed footwear as an effective intervention in the prevention of COVID-19 among health care workers in areas with possible direct patient care of COVID-19 positive patients and aerosol generating procedures. (Moderate quality of evidence; Strong recommendation) Consensus Issues Direct patient care1 is defined as hands on, face-to-face contact with patients for the purpose of diagnosis, treatment and monitoring. This recommendation was made by the panel as it prioritized giving the best available protection to the healthcare workers. Whenever possible, hospital administrators should invest in these PPEs. Strict adherence to the appropriate use of PPEs must be observed even if healthcare workers have already been vaccinated against COVID-19. 1 National Center for Emerging, Zoonotic and Infectious Diseases- Division of Healthcare Quality Promotion. (2020). The National Healthcare Safety Network (NHSN) Manual- Healthcare Personnel Safety Component Protocol: Healthcare Personnel Exposure Module. Atlanta, GA, USA: CDC. PPE in Hospital As of 17 April 2021 Philippine COVID-19 Living Clinical Practice Guidelines Key Findings Three studies and a case report were found on the use of PPE among health care workers to prevent COVID infection. Moderate certainty evidence from three studies showed that the use of Level 2 PPE (disposable hat, medical protective mask (N95 or higher standard), goggles (anti-fog) or protective mask (anti-fog), medical gown clothing or white coats covered by medical protective clothing, disposable gloves and disposable shoe covers), N95 respirators and face shields protected health care workers in hospital settings from COVID-19 infections. On the other hand, very low certainty evidence showed no significant protective effect from the use of face/surgical masks, gowns, and/or disposable gloves if used individually. Introduction The COVID-19 pandemic has placed the health care workers (HCW) at high risk of infection. The use of personal protective equipment (PPE) has been shown to be effective in preventing infection against related betacoronaviruses that have caused epidemics, such as severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS) [1,2]. PPE use depends on the risk of exposure, availability, and environmental control. The evidence on PPE recommendations, including the use of face mask, face shield, gowns and gloves, to prevent COVID 19 infection among health care workers are limited. Review Methods We searched MEDLINE, Cochrane CENTRAL, ChinaXiv, MedRXIV, BioRXIV and ongoing and completed trials on USA: https://clinicaltrials.gov/; China: http://www.chictr.org.cn/searchprojen.aspx and WHO: https://www.who.int/clinical-trials-registry- platform. We also searched for published/ongoing studies on the COVID-19 Open Living Evidence Synthesis: https://covid-nma.com/ and the Living Evidence on COVID-19: https://zika.ispm.unibe.ch/assets/data/pub/search_beta/. The initial search date was 31 March 2021 (updated 30 April 2021). The following keywords were used: ‘covid’, ‘COVID-19’, ‘coronavirus’, ‘SARS-CoV-2’, ‘viral’, ‘infection’, ‘respiratory’ ‘respirator’, ‘surgical mask’, ‘N95 mask’, ‘PPE’, ‘personal protective equipment’, ‘face shield’, ‘googles’, ‘eye protector’, ‘gown’, ‘gloves’, ‘health care worker’, ‘COVID- 19’, ‘coronavirus’, ‘SARS-CoV-2’. Subject headings and free text were combined 1. We included experimental or observational studies, meta-analysis/systematic reviews, completed trials and/or preprints that investigated the efficacy of PPE in preventing COVID 19 infection among health care workers in non-surgical areas (wards, ICU, emergency room). Two reviewers appraised the methodological quality of included studies using the Newcastle Ottawa Scale. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence related to the outcomes. 1 ((((((((((COVID 19[MeSH Terms]) AND health care w orkers (personal protective equipment[MeSH Terms])) OR (face mask[MeSH Terms])) OR (surgical mask[MeSH Terms])) OR (respirators[MeSH Terms])) OR (goggles[MeSH Terms])) OR (face shield[MeSH Terms])) OR (eye protector[MeSH Terms])) OR (gow ns, surgical[MeSH Terms])) OR (gloves, surgical[MeSH Terms]))) AND (health care w orker[MeSH Terms]) PPE in Hospital As of 17 April 2021 Philippine COVID-19 Living Clinical Practice Guidelines Results Characteristics of included studies Four observational studies (cohort, case control and cross sectional) and a case report were included. Two of these studies were also found in two systematic reviews [1,2] that reported on the association of COVID 19 infection with the use of PPE. Only data relevant to health workers in these studies were considered. Population of the studies were on health care workers mostly employed in health care facilities that attend to patients with COVID 19. Information on the various PPEs that were used by the health care workers while working in the health care facilities was gathered and their association with COVID 19 infection were assessed. Refer to Appendix 1 for detailed characteristics of these included studies. Methodological quality Four studies, two cohort [3,4], a case control [5] and a cross sectional [6], were assessed as having low quality and a case report [7] as very low quality The studies were direct evidence and with no inconsistencies, however with high risk of bias. For the three observational studies, two used a structured questionnaire [3] [6]and one reviewed infectious records [5] to gather data and thus subject to recall and information bias. Another study [4] was a surveillance data of COVID positive HCW before and after the implementation of the use of face shield. For the protective effect of the use of face shield in two studies [4] [6], confounders in the assessment could be its use together with the standard PPE, compliance of HCW on properly wearing it and in other preventive measures and the type of work done whether or not it is an aerosol generating procedure. Level 2 Protection Moderate quality evidence from a retrospective cohort study by Wang et al. [3] showed the protective effect of Level 2 protection among 5442 medical staff of Neurosurgery Departments of 107 hospitals in Hubei China (OR 0.03 [95% CI 0, 0.19]). Of the 120 who were infected , 54 were neurosurgeons and 66 were nurses involved with COVID 19 patients with patient contact time between 5 to 90 minutes (average time: 35 minutes) Level 2 in their center involved the use of the following: disposable hat, medical protective mask (N95 or higher standard), goggles (anti-fog) or protective mask (anti-fog), medical gown clothing or white coats covered by medical protective clothing, disposable gloves and disposable shoe covers. Additional data from a cross sectional study in Bangladesh involving 190 HCW in 19 health facilities [6], a possible protective effect in using PPE was reported (OR 0.15 [95% CI 0.02, 1.21]). The evidence was downgraded due to imprecision. However, the type of PPE used in this study was not specified; thus, this was not included in the analysis. N95 respirators Moderate certainty evidence involving 493 participants demonstrated a protective effect with the use of N95 respirators (OR: 0.035 [95% CI 0.002 to 0.603]). This was a case control study in Wuhan China [5] but was assessed as to have a large effect. Another study [6] from Bangladesh involving 190 health workers also demonstrated the N95 protective effect during aerosol generating procedure (OR 0.37 [95% CI 0.16-0.87]). PPE in Hospital As of 17 April 2021 Philippine COVID-19 Living Clinical Practice Guidelines Face mask In the cross-sectional study in Bangladesh [6], very low certainty evidence suggested that the use of medical/surgical masks while attending to COVID 19 patients was not associated with infection among 190 health workers (OR 1.40 [95% CI 0.30, 6.42]) [5]. The evidence was downg raded as very low due to imprecision. The study used a structured questionnaire which was answered by the participants and therefore subject to recall bias. A case report [6], however, showed that among 37 health care workers who were exposed to a COVID-19 patient, 3/34 (8.8%) who did not wear a mask were infected while none of the three who were wearing a mask were infected. Face shield Moderate certainty evidence [4] before and after face shield use was implemented demonstrated the protective effect of face shield with standard PPE among 6527 health care personnel (HCP) who were tested for COVID. (RR 0.297 [95% CI 0.228, 0.385]). The type of PPE used was not discussed. The data was from a surveillance study in a quarternary health care system in Texas. Biweekly testing for HCP in high-risk units (emergency department, transplant units and COVID- 19 units) and weekly testing for HCP in cluster areas (>= 3 cases of HCP with COVID-19 diagnosis or any case of hospital-acquired infection) were done. Testing was voluntary for HCP and HCP in other areas if they desire or if with exposure history. HCP with previous positive COVID-19 diagnosis were excluded. This was a cohort study and was initially graded as low but was upgraded due to the large effect.